Warning! Long post/Wall of text
I need some help in writing up a care plan for school. According to the rubric we're supposed to come up with 10 nursing diagnoses (listed in descending order of priority) and then do complete write ups of the top two. If a nursing diagnosis seems to be resolved/under control (ex. Pt. came in with acute UTI which was resolved after a period of antibiotics) then even though the diagnosis has more priority over another, we should not do a work up on the resolved diagnosis. I'm having some trouble with coming up with diagnoses as well as prioritizing them. Below I've included as much information as possible regarding my client as well as the nursing diagnoses I've come up with. Any help, additions or criticism (structural of course haha. No trolls please) would be awesome!
: Patient is a 62 year old male with a history significant for mental retardation, multiple LE (lower extremity) DVTs (deep vein thrombosis), and depression. Patient is unable to provide history secondary to AMS (altered mental status). Per nursing home records, patient was sent to ER for evaluation of facial droop. In ER, patient was negative for following commands and responsiveness to questioning, mumbling only. Unsure of symptom onset time to present. CT of head performed in ER indicates multiple new infarcts since 2011. UA (urinalysis) positive for nitrates and leukocytes. Suspect mandibular dislocation and pneumonia of right lung on CT scan. Patient admitted to r/o CVA.
: mental retardation, LE DVTs (multiple), subdural hematomas, depression, diverticulosis, anemia, kidney stones
: FVC filter
: Quinolones, heparin, porcine, penicillins, beef
: Alphaga P Opht, Consopt Opht, Travatan Z Opht (all eyedrops for glaucoma)
: [Hospital standard for normal ranges are in brackets next to lab value]
- BUN 28H [6-23]
- CL: 109 [98-109]
- CO2: 23.3L [24-32]
- Calcium: 8.3L [8.6-10.4]
- Albumin: 3.0L [3.5-5.5]
- Bilirubin: <0.01L [0.1-1.2]
*I only listed the abnormal labs
- Pt. non-verbal (only mumbles every now and then) and unresponsive to commands
- However, pt repeated would say "ow", "that hurts", or "I don't like it" during bed change/AM care
- Pt. unresponsive when asked about pain scale/area/type
- Unless prompted upon physical touch (ie. during a bed change or AM care), pt would otherwise be asleep. When awoken very lethargic an unresponsive.
- Thrush/Candidias on tongue since pt. either unable to or constantly kept mouth open
- Pt. has not eaten for past 4 days due to inability to close mouth
- Swallow consult was done (I don't know the results but the Pt. was later NPO)
- His brother (also legal guardian) wanted to hold off on putting in a PEG; brother says pt. is able to eat and swallow and wanted to try to get him to swallow before putting in a PEG
- Pt. very stiff and would say "Ow" and "I don't like it" during physical therapy
- Pt. would occasionally have a very mucousy sounding cough (not sure how to describe this in medical/nursing terminology)
- Would encourage pt. to spit out excess mucous but pt. would not spit out (unsure whether pt. had understanding of directions)
- Pt. would smile/turn head towards brother's voice, unresponsive to others unless physically stimulated
- Imbalanced nutrition less than body requirements related to lack of oral intake.
- Impaired gas exchange related to effects of alveolar-capillary membrane changes.
- Ineffective airway clearance related to accumulation of secretions.
- Activity intolerance as evidenced by verbalizations of pain during physical therapy.
I'm not sure how to phrase the last diagnosis (activity intolerance). The pt. is on strict bed rest and is also a fall risk. He has a foley catheter in place and had no bowel movements when I was in the hospital I'm assuming due to his lack of intake of food.
Sorry for the wall of text. If you need any more information PM me or let me know and I will post it if I have it!
Feb 26, '13
Ooo I have a better understanding now. Thank you so much! I really appreciate it
I have one more quick question if you don't mind. There's another patient I need to write a care plan on (two patients in total). This one I have a better grasp on since she is easier to assess.
She was admitted for right thumb pain and swelling. She ended up getting diagnosed with cellulitis of the right thumb. There is weeping of the skin on the lateral aspect of the right thumb and no purulent drainage as of yet.
My biggest concern is the patient developing sepsis as a result of the cellulitis. I have pretty much all the interventions and rationale for this diagnosis but I'm unsure of how to phrase the actual nursing diagnoses. I'll write what I wrote as the diagnosis.
Risk for systemic infection r/t cellulitis.
Is this enough? It seems too simple to me but I have no clue how to make it any more specific.
Last edit by leezee.loo on Feb 26, '13
: Reason: clarification
Feb 27, '13
by Esme12, ASN, BSN, RN Senior Moderator
She HAS an infection of her thumb....AEB.....
the reddening of the cellulitis of her thumb spread to around her wrist area in a direct line
Therefore THAT part of her care is clear. I don't know about your school....but "at risk for" is usually NOT considered a priority....over existing problems the patient actually HAS symptoms.
For example....you have a patient that is Short of breath (SOB).....they are no longer "at risk" for impaired gas exchange because you have EVIDENCE that they have this as an active diagnosis.
So for your patient.....you have EVIDENCE that this patient has an infection...therefore they are NO LONGER "at risk".
This would be clearer if you had a nursing diagnosis book to look you the NANDA definition of Risk for infection........
At increased risk for being invaded by pathogenic organisms
Chronic disease; inadequate acquired immunity; inadequate primary defenses (broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis); inadequate secondary defenses (decreased hemoglobin, leukopenia, suppressed inflammatory response); increased environmental exposure to pathogens; immunosuppression; invasive procedures; insufficient knowledge to avoid exposure to pathogens; malnutrition; pharmaceutical agents (e.g., immunosuppressants); premature rupture of amniotic membranes; prolonged rupture of amniotic membranes; trauma; tissue destruction
does you patient fit this criteria? A patient with diabeties is at risk for infections but that doesn't mean they actively have one.
Risk for decreased cardiac output r/t vasoconstriction (Pt. has a history of well managed hypertension. However upon admission she missed 1-2 of her medication for her hypertension so I figured she could still be at risk)
Risk for ineffective tissue perfusion r/t vasoconstriction. (Not sure if I can include this even though the relating factors are different than the first one. I figured I could since like I said before her HTN is well managed and therefore this is much less priority than the above dx)
Vaso-constriction of what? The NANDA definition of decreased cardiac output is......
Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body
Defining Characteristics (as evidenced by....)
Altered Heart Rate/Rhythm
Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia
Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain
Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings
Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds
Related Factors (r/t)
Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility
Your patient has.......
Impaired comfort r/t fatigue s/t disturbed sleep pattern
What does s/t stand for?
according to NANDA.......
Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental and social dimensions
Anxiety; crying; disturbed sleep pattern; fear; illness-related symptoms; inability to relax; insufficient resources (e.g., financial, social support); irritability; lack of environmental control; lack of privacy; lack of situational control; moaning; noxious environmental stimuli; reports being uncomfortable; reports being cold; reports being hot; reports distressing symptoms; reports hunger; reports itching; reports lack of contentment in situation; reports lack of ease in situation; restlessness; treatment-related side effects (e.g., medication, radiation)
According to the evidence you supplied...your patient has.....
Impaired comfort R/T pain AEB patient lack of sleep and complaints of pain.
Do you see???
Last edit by Esme12 on Feb 27, '13